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      Acute kidney injury due to high-output external biliary drainage in a patient with malignant obstructive jaundice: a case report

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          Abstract

          Background

          Persistent high output is a rare but potentially serious complication of percutaneous biliary drainage.

          Case presentation

          A 68-year-old Sinhalese woman with a palliative self-expanding metal stent placed for an inoperable hilar cholangiocarcinoma presented with worsening obstructive jaundice. Ultrasonography showed intrahepatic duct dilatation with the self-expanding metal stent in situ. Since this was indicative of a blocked stent, percutaneous transhepatic cholangiogram-guided internal biliary stenting through the self-expanding metal stent was attempted and failed. Therefore, an external biliary drain was left in the dilated biliary system. Post procedure, she developed a high biliary output of 3–4 liters per day and went into oliguric acute kidney injury with metabolic acidosis, most probably due to inadequate fluid replacement and hypovolemia.

          Conclusion

          Although the mechanism by which this occurs in some cases is unclear, early identification and prompt fluid resuscitation prevent acute kidney injury. The adoption of new strategies for internal drainage of long complex strictures will both prevent and ameliorate this problem.

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          Most cited references6

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          Malignant Biliary Obstruction: Evidence for Best Practice

          Leonardo Pu, Rajvinder Singh, Cheong Kuan Loong … (2016)
          What should be done next? Is the stricture benign? Is it resectable? Should I place a stent? Which one? These are some of the questions one ponders when dealing with biliary strictures. In resectable cases, ongoing questions remain as to whether the biliary tree should be drained prior to surgery. In palliative cases, the relief of obstruction remains the main goal. Options for palliative therapy include surgical bypass, percutaneous drainage, and stenting or endoscopic stenting (transpapillary or via an endoscopic ultrasound approach). This review gathers scientific foundations behind these interventions. For operable cases, preoperative biliary drainage should not be performed unless there is evidence of cholangitis, there is delay in surgical intervention, or intense jaundice is present. For inoperable cases, transpapillary stenting after sphincterotomy is preferable over percutaneous drainage. The use of plastic stents (PS) has no benefit over Self-Expandable Metallic Stents (SEMS). In case transpapillary drainage is not possible, Endoscopic Ultrasonography- (EUS-) guided drainage is still an option over percutaneous means. There is no significant difference between the types of SEMS and its indication should be individualized.
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            The value of bile replacement during external biliary drainage: an analysis of intestinal permeability, integrity, and microflora.

            S Kamiya, Takashi Asahara, Kenji Takagi … (2004)
            To investigate the effect of bile replacement following percutaneous transhepatic biliary drainage, ie, external drainage, on intestinal permeability, integrity, and microflora in a clinical setting. Several authors have reported that internal biliary drainage is superior to external drainage. However, it is unclear whether bile replacement following external drainage is beneficial. Twenty-five patients with biliary cancer underwent percutaneous transhepatic biliary drainage (PTBD) as a part of presurgical management. All externally drained bile was replaced either per os or by administration through a nasoduodenal tube. The interval between PTBD and the beginning of bile replacement was 21.3 +/- 19.7 days, and the length of bile replacement was 20.7 +/- 9.6 days. The lactulose-mannitol test, measurement of serum diamine oxidase (DAO) activity, and analyses of fecal microflora and organic acids were performed before and after bile replacement. The volume of externally drained bile varied widely from patient to patient, ranging from 220 +/- 106 mL/d to 1616 +/- 394 mL/d (mean, 714 +/- 346 mL/d). Biliary concentrations of bile acids, cholesterol, and phospholipids increased significantly after bile replacement. The lactulose-mannitol (L/M) ratio decreased from 0.063 +/- 0.060 before bile replacement to 0.038 +/- 0.032 after bile replacement (P < 0.05). Serum DAO activity increased from 3.9 +/- 1.4 U/L before bile replacement to 5.1 +/- 1.6 U/L after bile replacement (P < 0.005), and the magnitude of change in serum DAO activity correlated with the length of bile replacement (r = 0.483, P < 0.05). Neither the L/M ratios nor serum DAO activities before bile replacement correlated with the interval between PTBD and the beginning of bile replacement. Fecal microflora and organic acids were unchanged. Impaired intestinal barrier function does not recover by PTBD without bile replacement. Bile replacement during external biliary drainage can restore the intestinal barrier function in patients with biliary obstruction, primarily due to repair of physical damage to the intestinal mucosa. Our results support the hypothesis that bile replacement during external drainage is beneficial.
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              Current Status of Percutaneous Transhepatic Biliary Drainage in Palliation of Malignant Obstructive Jaundice: A Review

              SH Chandrashekhara, S. Gamanagatti, Anuradha Singh … (2016)
              Malignancies leading to obstructive jaundice present too late to perform surgery with a curative intent. Due to inexorably progressing hyperbilirubinemia with its consequent deleterious effects, drainage needs to established even in advanced cases. Percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) are widely used palliative procedures each with its own merits and lacunae. With the current state-of-the-art PTBD technique consequent upon procedural and hardware improvement, it is equaling ERCP regarding technical success and complications. In addition, there is a reduction in immediate procedure-related mortality with proven survival benefit. Nonetheless, it is the only imminent lifesaving procedure in cholangitis and sepsis.
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                Author and article information

                Contributors
                Umesh Jayarajah: umeshe.jaya@gmail.com
                Oshan Basnayake: oshanbasnayake@gmail.com
                Pradeep Kumara Wijerathne: hgpkwijerathne@gmail.com
                Sivasuriya Sivaganesh: 94-112671846 , sivaganesh@srg.cmb.ac.lk
                Journal
                Journal ID (nlm-ta): J Med Case Rep
                Journal ID (iso-abbrev): J Med Case Rep
                Title: Journal of Medical Case Reports
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1752-1947
                Publication date (Electronic): 13 August 2019
                Publication date PMC-release: 13 August 2019
                Publication date Collection: 2019
                Volume: 13
                Electronic Location Identifier: 251
                Affiliations
                [1 ]ISNI 0000 0004 0556 2133, GRID grid.415398.2, Professorial Surgical Unit, National Hospital of Sri Lanka, ; Colombo, Sri Lanka
                [2 ]ISNI 0000000121828067, GRID grid.8065.b, Department of Surgery, Faculty of Medicine, , University of Colombo, ; Kynsey Road, Colombo 8, Western Province Sri Lanka
                Article
                Publisher ID: 2195
                DOI: 10.1186/s13256-019-2195-4
                PMC ID: 6691544
                PubMed ID: 31405371
                SO-VID: 84e0a8ab-5713-4a20-90a9-c3b5d90362e2
                Copyright © © The Author(s). 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 17 January 2019
                Date accepted : 9 July 2019
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                ScienceOpen disciplines: Medicine
                Keywords: high output biliary drain,acute kidney injury,case report
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: high output biliary drain, acute kidney injury, case report

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